Nursing Elites

1. The nurse is caring for a client who has a chest tube in place following a pneumothorax. The nurse notes that there is continuous bubbling in the water seal chamber of the chest tube drainage system. What action should the nurse take?

• A. Check for kinks in the tubing
• B. Notify the healthcare provider
• C. Replace the chest tube drainage system
• D. Reinforce the chest tube dressing

Correct answer: B

Rationale: The correct action for the nurse to take when observing continuous bubbling in the water seal chamber of the chest tube drainage system is to notify the healthcare provider. Continuous bubbling indicates a possible air leak, and the healthcare provider needs to be informed to assess the situation and take appropriate actions. Checking for kinks in the tubing (Choice A) may be done initially but is not the priority when continuous bubbling is present. Replacing the chest tube drainage system (Choice C) and reinforcing the chest tube dressing (Choice D) are not immediate actions needed in response to continuous bubbling in the water seal chamber.

2. A client diagnosed with tuberculosis (TB) is placed on drug therapy with rifampin (Rifadin). The client should be instructed to report which effect(s) of the medication to the healthcare provider?

• A. Reddish-orange discoloration of body fluids
• B. Bloody or blood-tinged urine
• C. Blurring of vision
• D. Weight gain of more than 2 pounds in a week

Correct answer: A

Rationale: The correct answer is A. Rifampin (Rifadin) commonly causes a reddish-orange discoloration of body fluids, including urine, sweat, saliva, and tears. This is a harmless side effect but should be reported to the healthcare provider for monitoring. Choices B, C, and D are not typically associated with rifampin therapy. Bloody or blood-tinged urine may indicate other issues such as urinary tract infection or kidney problems, blurring of vision may suggest eye problems, and significant weight gain could be related to various health conditions unrelated to rifampin.

3. A 24-year-old female client who has a history of rheumatoid arthritis (RA) is taking ibuprofen (Motrin) for pain relief. Which information should the nurse provide the client about taking this medication?

• A. Take the medication with meals
• B. Take the medication with an antacid
• C. Report any changes in stool color to your healthcare provider
• D. Avoid taking aspirin while using this medication

Correct answer: C

Rationale: The correct answer is to instruct the client to report any changes in stool color to the healthcare provider. This is important because changes in stool color can indicate gastrointestinal bleeding, a serious side effect of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen. Choice A is incorrect because while taking ibuprofen with meals can help reduce stomach upset, it is not the most crucial information to provide. Choice B is incorrect as taking ibuprofen with an antacid is not a standard recommendation. Choice D is also incorrect because while ibuprofen and aspirin are both NSAIDs, they can be taken together under certain circumstances, but it's important to be cautious and follow healthcare provider recommendations.

4. The healthcare provider is caring for a client with jaundice. Which serum laboratory value is likely to be elevated for this client?

• A. Amylase
• B. Creatinine
• C. Blood urea nitrogen
• D. Bilirubin

Correct answer: D

Rationale: Bilirubin is a key serum laboratory value that is likely to be elevated in clients with jaundice. Jaundice is characterized by a yellowish discoloration of the skin and eyes due to an excess of bilirubin, a breakdown product of hemoglobin. Elevated amylase levels are associated with pancreatic conditions, not specifically jaundice. Creatinine and blood urea nitrogen are markers of kidney function and are not directly related to jaundice.

5. The nurse is planning care for a client who is receiving phenytoin (Dilantin) for seizure control. Which intervention is most important to include in this client’s plan of care?

• A. Monitor serum calcium levels
• B. Obtain a baseline electrocardiogram
• C. Implement seizure precautions
• D. Encourage a low-protein diet

Correct answer: C

Rationale: The correct answer is to implement seizure precautions. Phenytoin is an antiepileptic medication used for seizure control. Seizure precautions are crucial for clients taking this medication to ensure their safety during a seizure episode. Monitoring serum calcium levels (Choice A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (Choice B) is important for some medications but not the priority for a client on phenytoin. Encouraging a low-protein diet (Choice D) is not specifically indicated for clients on phenytoin and is not the most important intervention.

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